Elderwood At Williamsville

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the failure of nursing staff to verify and follow a resident’s documented Do Not Resuscitate (DNR) status and advance directives before initiating cardiopulmonary resuscitation (CPR). Facility policy on Basic Life Support required that CPR, rescue breathing, and defibrillation be initiated on all appropriate residents unless advance directives excluding these procedures were on file in the medical record. The resident involved had documented advance directives, including a health care proxy and an activated Medical Orders for Life Sustaining Treatment (MOLST) form specifying DNR and Do Not Intubate (DNI) status. Multiple records, including the care plan, order listing report, MOLST, and a provider note, consistently documented that the resident’s code status was DNR/DNI and that natural death should be allowed. On the day of the incident, the resident, who had diagnoses including dementia, depression, and coronary artery disease and was assessed as usually understood, usually understands, and moderately cognitively impaired, was found unresponsive in a folding chair in the bathroom. A certified nurse aide notified an LPN that the resident was unresponsive. The LPN went to the room, found the resident unresponsive and without a pulse or respirations, and paged the nursing supervisor STAT. The LPN then returned to the resident, confirmed there was no pulse, lowered the resident to the floor, and initiated chest compressions without checking the resident’s code status in either the paper chart or the electronic medical record, despite knowing that code status could be found on the MOLST form at the nurse’s station or under the resident’s picture in the electronic record. As the code progressed, additional nursing staff responded. The nursing supervisor entered the room while the LPN was performing CPR and asked about the resident’s code status. The LPN stated the resident was a full code, and the supervisor assumed the code status had been checked. Another RN assisted with chest compressions and also did not ask or verify the resident’s code status before participating in CPR. There was confusion when EMS arrived and requested the resident’s code status and MOLST form. An RN unfamiliar with the unit and experiencing issues with the nurse’s station computers had difficulty locating the paper chart, which delayed confirmation of the resident’s DNR/DNI status. Once the MOLST was found and reviewed, it showed the resident had DNR/DNI orders, but CPR had already been initiated and continued until EMS contacted their provider and terminated the code. The resident expired at the facility.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe dementia and incapacity to make medical decisions was subjected to inappropriate sexual contact by another resident. The incident took place in a common area after dinner, where a staff member witnessed one resident touching the other's breast under their shirt. The victim was unable to communicate or react due to severe cognitive impairment, and there was no evidence of consent. The perpetrator, who also had dementia and lacked capacity for medical decision-making, did not recall the event and displayed indifference when questioned. Prior to the incident, the care plan for the victim did not address the risk of potential victimization, nor was it revised after the event to reflect the new risk. The perpetrator's care plan noted moderate cognitive impairment and behavioral concerns, with interventions to monitor interactions for appropriateness, but there was no documented history of prior inappropriate behavior. Staff interviews confirmed that the incident was recognized as sexual abuse, and immediate separation of the residents occurred. However, documentation and monitoring for the safety of the victim and prevention of recurrence were not clearly established at the time of the incident. The facility's abuse prevention policy required protection of residents from abuse and outlined steps such as increased supervision and room changes to safeguard victims during investigations. Despite these policies, the lack of a care plan addressing the victim's vulnerability and the absence of immediate, documented interventions to prevent further abuse contributed to the deficiency. Staff responses varied in their understanding of the incident, with some not recognizing the event as abuse due to the perpetrator's cognitive status, while others identified it as non-consensual sexual contact.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, it was observed that corridor doors in a long-term care facility were not properly maintained, affecting three of the four resident use floors. Specific issues included doors that did not latch into their frames and were obstructed from closing. On the second floor, the Treatment Room door required a forceful close, and the Janitor's Closet door was obstructed by a paper towel and a decoration hanger. On the first floor, the Respiratory Therapy Office door was propped open with a garbage can, despite being equipped with a magnetic hold-open device. In the basement, the Ladies Locker Room door did not latch, and on the second floor, the door to Resident Room 222 appeared warped. The facility's computerized maintenance system indicated that fire and smoke door inspections were not specific to door locations and were not conducted frequently enough to address the issues. The last annual inspection was completed nearly a year prior, and the monthly inspection did not specify door locations. Interviews revealed that an outside contractor had been hired to repair and replace certain doors, but there was no written list of the doors included in the project. Maintenance staff recalled that Resident Room 222's door was part of the project. During a post-survey revisit, it was found that the deficiency persisted, with the Ladies Locker Room door still not latching. Staff education on corridor doors was inconsistent, with some staff members reporting no recent education on the topic. The facility's Plan of Correction indicated that corrective actions were either completed or in progress, but the Maintenance Director, who was responsible for the plan's implementation, was on leave. The Administrator was unaware that some doors had not been repaired and assumed the contractor would complete the repairs before the plan's completion date.

Plan Of Correction

Plan of Correction: N/A Corrective action for the deficient corridor doors at the Unit 2 treatment room, unit 2 janitor’s closet, unit 1 respiratory therapy office, the ladies locker room, and resident room 222 is completed or in progress by outside contractor. Education will be provided to all staff related to corridor door operation and to the maintenance team on proper operation of corridor doors. A Monthly audit will be conducted for all corridor doors. The results of this audit will be logged monthly into the TELS system. The results of this audit will be reported to the QA committee on a monthly basis. Administrator will provide the education. Monitored Monthly for 3 months in QA. Responsible Designee: Maintenance Director

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, it was observed that hazardous area doors in a facility were not properly self-closing and latching into their door frames. This issue was identified across all four resident use floors, including the basement, first, second, and third floors. Specific doors, such as those to the Precautions Bins Storage Room, Oxygen Storage Areas, Soiled Utility Room, Laundry Room, Central Supply, and Maintenance Shop, were found to have various issues preventing them from closing and latching properly. These issues included stuck latches, doors needing to be pulled to engage the latch, and doors being held open by ropes or magnets. The facility's computerized maintenance system indicated that fire and smoke door inspections were not specific to door locations and were not conducted frequently enough to ensure compliance. Interviews with the Director of Facilities Maintenance and other staff revealed that some doors had been repaired by an outside contractor, but there was no written list of doors assigned for repair. Additionally, the maintenance staff had not been adequately trained on inspecting and maintaining these doors, contributing to the ongoing deficiencies. During a post-survey revisit, it was found that the deficiencies persisted, with doors on the first and third floors still not self-closing and latching. Staff interviews revealed a lack of comprehensive education on the importance of maintaining hazardous area doors, with some staff unaware of the issues or the necessary corrective actions. The facility's Plan of Correction was not fully implemented, and the absence of the Maintenance Director further complicated the resolution of these deficiencies.

Plan Of Correction

Plan of Correction: N/A Corrective action for the deficient doors located on Unit 5 precaution bin storage, Unit 2 oxygen storage area, Unit 3 oxygen storage area, Unit 1 oxygen storage area, Unit 1 soiled utility room, laundry room rear door, central supply door, and the maintenance shop area are corrected or in progress completion by outside contractor. Education will be provided to all staff related to proper door closure and to the maintenance team on proper technique for checking all interior doors. An audit will be conducted for all facility interior doors. This will be logged in the TELS system, and the results will be reported to the QA committee on a monthly basis. Administrator to provide all education and we will continue to monitor the doors monthly and annually. Monitored monthly for 3 months in QA. Responsible designee - Maintenance Director

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, it was observed that smoke barrier walls in a facility were not properly maintained, affecting three of the four resident use floors. Specifically, the smoke barrier walls were incomplete from floor to ceiling/roof deck, lacked a 30-minute fire resistance rating, and had open and unsealed penetrations that could allow smoke passage. Observations revealed multiple unsealed penetrations above ceiling tiles on various floors, including outside resident rooms and in the MDS Office. These penetrations were noted to have wires and cables passing through them, which were not sealed, compromising the integrity of the smoke barriers. A follow-up Onsite Post-Survey Revisit found that the issue persisted on one of the floors, indicating a continuing deficiency. The facility's Plan of Correction had stated that the penetrations were sealed, but observations during the revisit showed otherwise. Interviews revealed that the Maintenance Director, who was responsible for implementing the Plan of Correction, was on leave, and the Maintenance Assistant was unaware of the penetrations. The Administrator, in the absence of the Maintenance Director, assumed responsibility for the Plan of Correction but was informed that the penetrations were sealed on the day they were identified, which was not the case.

Plan Of Correction

Plan of Correction: N/A Corrective action for the deficient smoke barrier on unit 4 resident room 333, MDS office on unit 2, resident room 233, and in the wall between the atrium and unit 1 have been sealed. Education will be provided to the maintenance staff on the proper procedure for checking for gaps in smoke barriers. An audit will be conducted to check all smoke barriers in the facility. This will be logged in TELS and the results will be reported to the QA committee on a monthly basis. Administrator will provide education. Weekly audits for 3 months. Reviewed monthly for 3 months in QA. Responsibility Designee - Maintenance Director.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, a portable electric space heater was found operating in the basement of a facility, specifically in the Environmental Services Office. The heater was not documented to ensure its heating element did not exceed 212 degrees Fahrenheit, violating the 2012 edition of the National Fire Protection Association 101: Life Safety Code. The Director of Facilities Maintenance was unaware of the heater's presence and stated that space heaters were not allowed in the facility. The Housekeeping/Laundry Supervisor, who shared the office, also denied knowledge of the heater's use, suggesting it might have been turned on by an employee who used the office earlier. Upon a revisit, another portable electric space heater was found plugged in and ready for use in the same office, with a second heater nearby. The heater was improperly placed close to flammable materials, and no documentation was available to confirm the heating element's temperature compliance. The Director of Environmental Services denied ownership of the heaters and had not received formal education on space heater policies since the initial survey. The Administrator was unaware of the new heaters and acknowledged that audits should have been conducted to prevent such occurrences. The facility's Plan of Correction included removing the heater and conducting in-service training on the prohibition of space heaters. However, interviews with staff revealed a lack of formal education on the matter, and the audit process was insufficiently documented. The Maintenance Director, responsible for implementing the Plan of Correction, was on leave, leaving the Administrator to oversee the process. Despite weekly audits, the Environmental Services office was not consistently checked, contributing to the recurrence of the deficiency.

Plan Of Correction

Plan of Correction: N/A Corrective action for this deficient practice was to remove the portable space heater from the Environmental Services office. A full-house audit will be conducted to check for portable space heaters. An in-service on the prohibition of portable space heaters will be conducted to staff who have offices. Ongoing compliance will be monitored by the Director of Maintenance/designee. The results of the weekly audit will be reported to the Monthly QA committee. Administrator will provide education. Weekly audits will be completed for 3 months. Audits will be reviewed Monthly in QA for 3 months. Responsible Designee - Maintenance Director

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment for Resident #154, who was severely cognitively impaired and at high risk for elopement. On 7/13/2024, the resident wandered off the 2nd floor Memory Care Unit without staff knowledge, exited through an emergency stairwell door that did not alarm, and left the building. The resident subsequently tripped and fell, sustaining a 2.5 cm laceration and hematoma to the head, as well as abrasions to the midback and right knee. This incident resulted in actual harm to the resident. The facility's policies on elopement and electronic wandering security were not adequately followed. Although the resident was identified as a high risk for elopement upon admission, the care plan did not initially include interventions for elopement risk. A wander alert bracelet was not applied until after the incident, and there was no evidence that the alarms were verified as functioning at the time of the elopement. Staff interviews revealed that no alarms were heard, and the facility did not have a properly fitting bracelet available immediately after the incident. The facility's response to the incident was delayed and inadequate. Staff were unaware of the resident's absence until a visitor found the resident outside and alerted the front desk. The resident was new to the facility, and there was a language barrier that complicated identification and communication. The facility's failure to apply a wander alert bracelet promptly and ensure functioning alarms contributed to the resident's unsupervised exit and subsequent injury.

Plan Of Correction

Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? For Resident #154, the Elopement Risk Assessment was initiated on 7/12/24 and completed on 7/17/24. The care plan was revised on 7/15/2024 to reflect that the resident was at high risk for wandering and elopement related to impaired cognition and memory. Nursing interventions were outlined on the care plan. The resident was discharged from the facility on 7/24/24 to a lower level of care. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 7/6/24, 7/13/24, 7/20/24, and 7/27/24 and were documented as functioning. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The QA Committee met on 2/12/25, to complete an assessment of causative factors and to identify an appropriate plan to prevent recurrence. It was determined that all residents have the potential to be affected by the same deficient practice. The Nursing Unit Manager(s) will complete an elopement risk assessment on all residents to identify a baseline for every individual and will be completed by 2/21/25. Any resident who is identified at risk for elopement will have their care plan reviewed to ensure their risk is identified and that an adequate care plan has been developed to ensure the resident’s environment remains free from accident hazards, that adequate supervision and assistive devices to prevent accidents are in place at that time. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 2/1/25 and 2/8/25 and were documented as functioning. All egress doors are equipped with functioning alarming devices that are easily audible by all staff in all areas of the unit, including when in a room with a closed door. The Unit Clerks will verify that all current residents have a facility issued wristband placed on their person and that hospital identification bands are removed by 2/21/25. The Administrator verified that an appropriate amount of well-fitting wander alert devices were available in the event any residents were to require this type of intervention on 2/12/25. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure that the residents’ environment remains free from accident hazards and that adequate supervision and assistive devices to prevent accidents are provided, the following measures will be implemented: All licensed nurses will be re-educated on the facility’s policies titled Elopement Risk Assessment, Electronic Wandering Security System, and Guidelines for Care Planning Wandering/Elopement High Risk Residents that outlines when elopement risk assessments are to be completed, when appropriate safety measures are to be implemented, and documented on the care plan once risk level for unsafe wandering/elopement is identified. The facility’s policy titled Preventative Maintenance Program was reviewed and remains appropriate. Maintenance Staff will be re-educated on the policy and the required weekly functionality verification of egress door alarms and door security devices. The Front Desk Receptionists, Unit Clerks, and Medical Records staff will be educated on the facility’s policy titled Resident Identification / Patient Identifiers and their responsibility of placing facility identification wrist bands upon admission to the facility to ensure residents are adequately identified in emergency situations. The facility’s assessment and minimum staffing plan will be reviewed and/or revised by the facility administrator to ensure adequate supervision and to prevent accidents. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Nursing / designee will conduct an audit of all new admissions within 24 hours of admission x 2 weeks, then weekly x 2 weeks, then monthly for a period of 2 months, to ensure Elopement risk assessments are completed as required, that appropriate safety measures have been implemented, that care plans are updated to reflect high risk residents, and that wander guard ankle bracelets have been placed when deemed necessary for residents at high risk. The Administrator, in conjunction with Maintenance staff, will conduct a monthly audit x 3 months ensuring that egress door alarms and door security devices have been checked weekly through the Preventive Maintenance Program and that are all functioning as intended. The Unit Clerks will conduct a weekly audit of all new admissions x 4 weeks, then monthly for a period of 3 months, to ensure facility identification bands are present and hospital identification bands removed for all new admissions/readmissions. The Director of Nursing will review daily staffing schedules weekly x 4 weeks, and then monthly for a period of 3 months, to ensure minimum staffing is in place to provide adequate supervision to prevent accidents. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on 3/7/25.

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaint investigations and observations. The facility's staffing levels were consistently below the required minimums, with reports indicating that the average hours of care per resident per day were significantly lower than the mandated 3.5 hours. Observations and interviews revealed that call lights were left unanswered for extended periods, and residents were not receiving timely assistance with basic needs such as repositioning, toileting, and meal service. Interviews with staff members, including CNAs and LPNs, highlighted the challenges faced due to inadequate staffing. Staff reported being unable to complete their duties, such as providing showers, toileting residents, and assisting with meals, due to the high resident-to-staff ratios. The lack of sufficient staff also led to delays in medication administration and inadequate supervision of residents, particularly those with higher acuity needs or behavioral issues. Residents and their families expressed dissatisfaction with the care provided, citing long wait times for assistance and unmet care needs. The Resident Council and Ombudsman also reported concerns about staffing levels, with residents describing instances where call lights were ignored, and staff were unable to provide timely care. The facility's failure to maintain adequate staffing levels compromised the safety and well-being of its residents, as evidenced by the numerous complaints and observations documented in the report.

Plan Of Correction

Plan of Correction: Approved February 20, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The following corrective actions for those residents who were found to have been affected by the deficient practice: Five complaint investigations were conducted (#NY 668, #NY 735, #NY 153, #NY 833, and #NY 434) during annual survey which ended on 1/21/25. It was determined that the facility allegedly did not ensure that there was sufficient staffing on multiple dates throughout the [AGE] year, based on the previously referenced complaints and staff/resident interviews conducted during the annual survey. No residents were affected by this deficient practice. The Social Service Director/designee will review with all residents who are alert and oriented in person and/or will contact the responsible parties of those residents with cognitive impairment, to discuss the facility's active plan to recruit and retain staff. The recruitment and retention plan will be reviewed at the next resident council meeting. The Administrator/designee will also discuss the “Ambassador program” that was created to foster relationships between management team members and new staff. The facility also has a “Manager on Duty” program to assist on weekends with staffing challenges; this includes the majority of management in the facility. Nursing leadership coverage rotates on a weekly basis, with all members of the nursing leadership team assisting with off-hour and weekend assistance. The Daily Nursing report (BIPA) is reviewed daily to ensure the number of nursing hours worked and the number of nursing staff working each shift based on census met the minimum staffing requirements. The facility will work with the Corporate Recruitment manager to discuss alternative recruitment initiatives. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/Assistant Director of Nursing ensure the health and wellbeing of the residents by having responsibility for oversight and operations of the nursing department. The DON and ADON, along with the Unit Nursing Managers, have been present on many shifts over the course of the last year. These include occasions when there were call-offs, weather-related issues, and other staffing challenges to help ensure adequate clinical specialists were on-site to provide care to the residents. The facility assessment and minimum staffing plan was reviewed and revised on 2/12/25 to include the use of a supplemental staffing agency. The Emergency Preparedness plan was reviewed on 2/12/25 to address staffing, which includes the use of a supplemental staffing agency. The facility labor disruption policy was reviewed on 2/12/25 to ensure interventions to address insufficient staffing are identified and staff will be re-educated on the process of when to activate the emergency staffing plan. When resident census changes, when staff call off or additional staff are called in to assist with staffing, the number of nursing hours worked, the number of nursing staff working each shift, and census will be updated on the Daily Nursing Report Sheets (BIPA). The Daily Nursing Report sheets along with the Facility Assessment minimum staffing ratios identified in the Facility Assessment will be compared to the daily clinical staffing sheets to ensure clinical daily schedules adequately reflect that staffing minimum hours are being achieved every shift according to the facility assessment. The Administrator, the DON, and the Staffing Coordinator will continue to review staffing daily and implement procedures to ensure sufficient staff are available to meet residents’ needs. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: To ensure that this deficient practice does not re-occur, the Administrator/Director of Nursing will provide educational training consisting of but limited to: 1. Facility policy and procedures on Facility Wide Assessment Tool consisting of the facility's clinical minimum staffing requirements. 2. Facility policy and procedures on Labor Disruption Policy and when to activate plan. 3. Facility policy and procedures on Emergency Staffing Plan and when to activate the plan. 4. Facility policy and procedures on completing and reviewing the Daily Nursing Report Sheet. 5. Nursing Managers and Nursing Supervisors will be re-educated on procedures when to notify the Administrator, Director of Nursing, and the Assistant Director of Nursing when there are vacancies and nursing call-offs that impact the facility not meeting minimum clinical staffing requirements as identified on the Facility Assessment. 6. All in-services will be completed by 3/12/2025. Nursing Unit Managers, Nursing Supervisors, and all other nursing exempt staff will be educated by the Administrator/Director of Nursing on the facility's minimum staffing numbers identified in the facility assessment and what to do if the numbers drop below the minimum requirements. This will include what to do, who to call regarding call-offs/no call no shows, and what other nursing personnel to contact to try and fill the vacancy issues when dropping below minimum staffing requirements. A new on-call schedule was developed to provide to backfill vacancies that are unable to be filled. The on-call schedule does not include the DON as the facility census is above 60. Discussions regarding recruitment and retention initiatives will be added to the monthly resident council meeting agenda for three months. Grievances will be reviewed daily for staffing concerns during morning report. The Clinical Staffing Coordinator will audit the daily staffing sheets, the daily nursing report sheets (BIPA), the facility assessment minimum staffing ratios, and the daily census daily for three months to ensure minimum staffing compliance. The Administrator in conjunction with the Director of Nursing will continue to review the facility's schedules weekly for three months to ensure sufficient staff have been scheduled to attain and maintain the highest practicable physical, mental, and psychosocial well-being of residents. With support from the Corporate Recruitment Team and Chief Operating Officer involvement, continued Recruitment meetings will take place weekly to monitor recruitment initiatives. The facility will continue to provide daily staffing needs updates to the Staffing Agency vendor to try and fill daily open shifts. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents across multiple units. During the survey, it was observed that food items were served at suboptimal temperatures, with hot foods often being lukewarm or cold, and cold foods being warmer than recommended. The facility's policy required hot foods to be maintained between 140-160 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit, but these standards were not met during meal service. Residents expressed dissatisfaction with the quality and temperature of their meals during Resident Council Meetings and interviews. They reported that food was often served cold, lacked flavor, and did not include requested condiments. Specific complaints included cold coffee, bland Salisbury steak, and warm milk. Residents also noted that the menu did not always match what was served, and there were frequent omissions of items like condiments. Staff interviews revealed awareness of the issues, with some attributing the problems to the plate warmer used on the tray line. The Registered Dietician and Assistant Director of Dining Services acknowledged that food temperatures were not within the safe range and that the milk should be kept colder. Despite these acknowledgments, the facility did not take adequate steps to address the deficiencies, resulting in continued resident dissatisfaction and potential health risks due to improper food handling.

Plan Of Correction

Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #53, #68, #94, #97, #131 were the impacted residents – two residents discharged (#131 & #53). The remaining 3 residents will have the director of dining services interview each of them related to the deficient practice. The director will continue to work with each of these residents to maintain their satisfaction. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be impacted by the same deficient practice. The director/designee will work with all residents. The director of social work/designee will interview all residents to determine satisfaction with their meals. The results of these interviews will be tracked and issues alerted to the dining services director/designee. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Director of Dining will provide in-service training to all dietary staff, no later than 2/28/25, to include appropriate food temperature requirements and holding time, the palatability of food, and appetizing meals. The director of dining services/designee will in-service the cooks on following the recipe, to ensure foods are prepared according to the appropriate method, ensuring taste and nutritional value. The director of dining services will educate the dietary staff on methods to keep cold food appropriately below 41 degrees, through the use of refrigeration/freezers/or ice. In order to maintain proper hot food temperatures (between 140 and 160), the team will use the newly purchased “hot plate warmer” and maintain food temperatures of hot items in the oven or steam-well. The use of the plate warmer will help to maintain proper hot food temperatures. The dietary staff will be pouring hot beverages just prior to meal service at each meal to ensure proper coffee/tea temperatures. The internal temperature of the coffee machine will be increased to improve temperatures at the time of service. The director of dining services/designee will monitor temperatures when food is ready to serve and at the end of service for resident meals. This will include hot and cold temperature checks to ensure both safe and palatable temperatures are maintained. Appropriate action will be taken if the food is not to proper temperatures – warmed up for cold food and refrigerated/chilled for items that are not cold enough. All cooks will record food temperatures to discover any variations to the required temperatures. Any issues discovered will be reported to the director of dining services/designee and issues will be corrected immediately to obtain proper temperatures. The director of dining services/designee will attend resident council, upon resident request to address any food concerns. Grievances related to food concerns will be reviewed daily in morning report and actions to address any concerns will be implemented. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Test trays will be conducted at each meal for one week, daily for 3 weeks, and then weekly for 2 additional months to observe palatability, temperature, and appearance. These observations will be provided to the Director of dining services/designee. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have deficiencies in the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an observation of the Main Kitchen, it was noted that the ceiling was covered in a layer of dark gray dust, affecting the ceiling tiles, grid, vents, sprinkler heads, and heat detectors. The Director of Dining Services acknowledged that the ceilings were not cleaned by the Dietary staff and should have been addressed by the Maintenance staff. However, a maintenance work order was not submitted, and the issue was not communicated to the current Maintenance staff after the former Director of Maintenance left the facility. Additionally, inspection reports from an outside contractor indicated that the heat detectors in the kitchen were dirty, with one detector being caked in dust and needing relocation. Further observations revealed a damaged wall behind the extinguishment hood in the Main Kitchen, with chipped and cracked paint and drywall paper peeled. The Director of Dining Services confirmed that the wall required repair and that clean dishes were stored against it. Interviews with the Director of Facilities Maintenance and the Administrator indicated that kitchen cleaning responsibilities were divided between Dietary and Maintenance staff, with deep cleaning and repairs needing to be scheduled during off-hours. Despite being aware of the issues for several months, the Director of Dining Services and the Administrator did not ensure that the necessary maintenance work was completed, leading to the continued presence of these deficiencies.

Plan Of Correction

Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? All areas of the kitchen were thoroughly cleaned, including walls and ceilings. The areas specifically mentioned as deficient were resolved; the ceiling tile grid, the vents, sprinkler heads, and heat detectors were cleaned prior to the conclusion of the annual survey. The wall areas noted to be damaged have been repaired. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be impacted by this deficient practice. The cleanliness of the kitchen will be monitored by the director of dining services. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? A cleaning schedule will be developed collaboratively between the director of dining services and the director of maintenance to maintain cleanliness of the kitchen, specifically the ceiling which would be difficult for dietary staff to maintain. The ceiling tiles, sprinkler heads, vents, and heat detectors will be cleaned on a monthly basis and as needed to maintain the sanitary conditions of the kitchen. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Dining Services will complete environmental audits monthly for 3 months to identify any dust-laden ceilings or damaged walls. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's emergency generator was found to be inadequately maintained during a Life Safety Code survey. The survey revealed that there was no documentation of annual diesel fuel quality testing for the years 2023 and 2024, with the last recorded test being in March 2022. The Director of Facilities Maintenance/Corporate was unable to provide documentation for these years and stated that the outside contractor responsible for maintenance typically handled fuel testing and documentation. Additionally, there were gaps in the generator's monthly load test records, with missing documentation for specific periods in 2024. The computerized maintenance system showed incomplete records for these tests, lacking essential details such as hour meter information. Furthermore, the survey identified that the emergency manual stop station for the generator was not located in a remote area, as required. The only stop station was found on the generator itself, and staff, including the Administrator and Director of Facilities Maintenance/Corporate, were unaware of any remotely located stop station. This lack of awareness extended to the Maintenance Assistant, who had been conducting load tests due to a vacancy in the Director of Maintenance position. The absence of a remote stop station and the lack of knowledge among key staff members about its location were significant findings in the survey.

Plan Of Correction

Plan of Correction: Approved February 24, 2025 Corrective action for the areas found to be deficient were to obtain fuel samples on an annual basis, conduct monthly generator load tests, and add a remote emergency stop to the generator. Outside Contractor provided documentation for 2024; however, results for 2023 were not found. The remote emergency stop will be installed by outside contractors. Audits will be conducted by the Maintenance Director consisting of a monthly load test on the generator, which includes the fuel and oil checks as well as the remote emergency stop button for proper functioning. A weekly no load test will be conducted. Education will be provided to the Director of Maintenance to maintain compliance with generator regulations. The monthly testing will be recorded in the TELS system. The results of the audits will be reported to the QA committee on a monthly basis. The Administrator will provide education to the Maintenance Director. Reviewed monthly in QA for 3 months. Responsible - Maintenance Director will train the maintenance team. Maintenance Director will implement the P(NAME).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During a Life Safety Code survey, it was observed that required exit signs did not correctly indicate the egress path on two of the four resident use floors, specifically the basement and first floor. On the first floor, an illuminated exit sign in the Main Kitchen was mounted perpendicular to the exit stairway, with both left and right chevrons lit, misleadingly indicating egress through the service elevator or mop closet. A paper sign on the exit stairway door incorrectly stated 'This is no longer an exit,' contradicting the fire evacuation diagram that showed the exit stairway as the primary egress route. Additionally, in the dish wash area of the Main Kitchen, an exit sign incorrectly indicated egress through the dish machine alcove and service elevator lobby, conflicting with the fire evacuation diagram. Further observations on the first floor revealed an exit sign in the service elevator lobby without chevrons, suggesting an incorrect path through a solid wall. In the lobby outside the Atrium, an exit sign incorrectly lit only the chevron pointing into the Atrium, despite both the Atrium and main entrance being valid egress routes. In the basement, an exit sign above double doors in the Boiler Room had chevrons coated with white paint, obscuring the correct egress path. These discrepancies in exit signage were acknowledged by the Director of Facilities Maintenance/Corporate, who noted the need for corrections to align with the appropriate egress routes.

Plan Of Correction

Plan of Correction: Approved February 21, 2025 Corrective action for the deficient exit signs in the kitchen stairway door, the kitchen dish wash area, basement service area, lobby outside of the atrium, and the double doors in the boiler room have been adjusted and are functioning properly. A full building audit will be conducted to verify the accuracy of all facility exit signs; this will be monitored through the TELS system. Education for the maintenance staff will be provided on exit signs operation. Ongoing compliance will be monitored by the Director of Maintenance and reported to the QA committee on a monthly basis. The Administrator will provide education; we will review our tasks in our computerized maintenance system. Exit signs will be checked monthly for 3 months in QA. Responsible designee - Maintenance Director. Policy and Procedure will be reviewed as part of the P(NAME).

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency identified during the Life Safety Code survey was the failure to conduct fire drills at least once per shift per quarter, as required by the facility's Fire Drill Policy. The policy, approved in June 2023, mandates that fire drills be scheduled by the Director of Maintenance, Nurse Educator, or a designee to ensure staff preparedness in the event of a fire. However, a review of fire drill reports revealed that only two fire drills were conducted during the second quarter of 2023 and two during the third quarter of 2024, failing to meet the requirement of one drill per shift per quarter. Interviews with facility staff, including the Director of Facilities Maintenance and the Registered Nurse Infection Preventionist Nurse Educator, highlighted issues in the scheduling and documentation of fire drills. The Maintenance staff was primarily responsible for planning the drills, but it was sometimes a joint effort with the Education staff. The Administrator confirmed that the Maintenance Director was responsible for maintaining fire drill documentation, but the individual in that role during 2023 and 2024 was no longer employed at the facility, contributing to the lack of proper documentation and execution of the required fire drills.

Plan Of Correction

Plan of Correction: Approved February 21, 2025 Corrective action for the deficient practice is to conduct monthly fire drills as required. The Director of Maintenance and Nursing Educator will be educated on the requirements for completion on each shift (days, evening, nights) every quarter. An audit will be conducted on a monthly basis for completion of that month’s drill, verification that drill was during proper shift, and the next month’s drill shift is planned. Ongoing compliance will be monitored by the Director of Maintenance and logged in the TELS system. The results of the audit will be reported to the QA committee, for both the current and following month for continued compliance. The Administrator will provide the education and review Policy and Procedure with staff. Maintenance Director will perform Monthly Audits and Drills Presented in QA for 3 months. Responsible Designee - Maintenance Director

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain continuous illumination of egress pathways, as required by the Life Safety Code. On the first floor, the corridor lighting in the Administrative wing was controlled by two light switches, and when these were turned off, no lighting remained on between the reception desk and the west end, which forked into two corridors. This area, approximately 96 feet in each branch, served as egress routes between the west stairway and the main entrance, as indicated by illuminated exit signs. This lack of continuous illumination could impede safe evacuation in the event of an emergency. Additionally, the exterior of the facility lacked adequate lighting above certain exit doors. Specifically, there was no light fixture above the C Stairway exit door, with the closest light being approximately six feet away, and no light fixture above the Physical Therapy exit door, with the closest light being a pole light approximately 25 feet away. During a second observation before sunrise, it was noted that the closest lights to these exits were not lit at certain times, although inside lighting was visible through the glass doors and walls. The Director of Facilities Maintenance indicated that new pole lights had been added and electricians were testing the exterior lighting, which may have caused the observed inconsistencies.

Plan Of Correction

Plan of Correction: Approved February 21, 2025 Corrective action for the deficient areas of lighting was performed by outside vendor. Contractor installed wall pack lights with 2 bulbs above affected doors. The first-floor administrative corridor will have seven corridor lights which will be wired to be on at all times. The exterior lighting issues at both the C stairway exit and the physical therapy exit have been corrected. Education will be provided to the Director of Maintenance to maintain compliance with proper lighting throughout the facility, as required by this regulation. A weekly audit will be completed to check for illumination throughout the inside and exterior of the facility. Any deficient lighting systems will be entered into the TELS system and corrected at that time. The results of the audit will be reported to the QA committee on a monthly basis. This will be monitored monthly in QA for 3 months. Administrator will provide education to the Maintenance Director and maintenance team. Responsible Designee: Maintenance Director

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of Certified Nurse Aide #10 towards two residents. Resident #46, who had severe cognitive impairment due to conditions such as cerebral infarction and dementia, was subjected to undignified treatment when Certified Nurse Aide #10 made a fist and a boxing jab motion towards them. Additionally, the aide wheeled Resident #46 into a corner, leaving them facing the wall in a common area. This behavior was observed on video footage and was described as inappropriate and potentially intimidating, especially given the resident's cognitive deficits. Resident #81, who also had severe cognitive impairment due to dementia and Parkinson's disease, was similarly mistreated. Certified Nurse Aide #10 was observed pushing Resident #81 in their wheelchair with the front wheels lifted off the ground, performing a 'wheelie' motion. This action was captured on video and was considered unsafe and undignified, as it could have caused fear or harm to the resident. The comprehensive care plans for both residents indicated that they required assistance with mobility and had potential for mood or behavior alterations, necessitating a respectful and supportive approach from staff. Interviews with facility staff, including the Human Resource Manager, Certified Nurse Aide #11, Activity Leader #1, and the Director of Nursing, confirmed that the actions of Certified Nurse Aide #10 were inappropriate and did not align with the facility's dignity policy. The staff emphasized that residents, particularly those with cognitive impairments, should not be subjected to actions that could be perceived as threatening or disrespectful. The facility's policy on dignity requires that all interactions with residents focus on maintaining and enhancing their self-esteem and self-worth, which was not upheld in these instances.

Plan Of Correction

Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #46 and #81 were both interviewed by the Director of Social Services to ensure they are being treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality at the time of the incident. Both residents appeared to have no negative impacts from the facility self-reported occurrences, which include no behaviors that would have implied they had concerns with abuse or dignity. #46 has been discharged. #81 does have cognitive impairment, and their legal representative was notified and interviewed, and no concerns were reported. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. The Director of Social Work/designee(s) will interview all residents and/or responsible representatives (if the resident is unable to participate) to ensure they are treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality. Any reports of not being treated with respect and dignity will be investigated and reported as required. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The nurse educator will re-educate all staff on the facilities Resident Rights and Dignity policy to ensure each resident is treated with respect and dignity and receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Monthly at the resident council meeting, the topic of dignity will be reported on, to maintain resident expectations for the treatment received from staff, while a resident within the facility. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Social Work/designee will conduct 15 quality of life/dignity interviews with the residents or resident representatives (3 residents per unit) for a period of 3 months. Any reports of not being treated with respect and dignity will be investigated and reported as required. Results of the interviews will be submitted to the QA committee for review. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their mobility. Specifically, the resident, who was cognitively intact and required supervision for ambulating, was not ambulated daily as recommended in their care plan. The resident had diagnoses of lymphedema and chronic pain syndrome and was on a nursing rehab ambulation program that required stand-by assistance for walking 10 to 15 feet with a rolling walker. However, records showed that the resident was only walked on a few specific dates over a month-long period, contrary to the daily ambulation plan. Interviews with the resident and staff revealed that the resident expressed concern about not being walked regularly, fearing a loss of mobility. Staff members, including a Certified Nurse Aide and the Registered Nurse Unit Manager, acknowledged that due to staffing shortages, the ambulation program was not consistently implemented. The Director of Rehabilitation and the Director of Nursing both stated that they expected staff to follow the care plan, which included daily ambulation for the resident. The failure to adhere to the care plan was attributed to insufficient staffing, which hindered the ability to provide the necessary care to maintain the resident's mobility.

Plan Of Correction

Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #51 was reassessed by therapy to ensure there was no decline in residents' ROM or abilities, which revealed there were no changes in ADL abilities. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents who are care-planned for an ambulation program are at risk for the same deficient practice. All residents with an ambulation program will be reviewed to ensure ambulation programs are appropriate and being completed as planned. Any adjustments required to the plan will be made at that time. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure residents receive appropriate treatment to prevent decline, the facility’s Ambulation Program policy was reviewed, and no changes were identified to be needed. All nursing staff responsible for implementing and overseeing ambulation programs will be re-educated on the facility's policy. The therapy department will provide a weekly list to the nursing department indicating what residents are care planned for an ambulation program. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Unit Managers will conduct weekly audits for 1 month, then monthly audits for a period of 2 months, verifying that ambulation programs are being implemented. Audits will include documentation review, as well as resident interviews. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

Fine: $75,553

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in managing the catheter and preventing urinary tract infections. The resident, who had a history of urinary tract infections and other urinary conditions, was observed with their foley catheter drainage bag improperly positioned above the level of the bladder, which is against the facility's policy. The drainage bag was also placed on the floor, and the tubing was kinked, both of which pose infection control risks. During multiple observations, staff members were seen placing the drainage bag in incorrect positions, such as on the wheelchair handle or armrest, and even directly on the floor. These actions were contrary to the facility's policy, which requires the drainage bag to be hung below the bladder level to ensure proper urine flow and prevent backflow, which can lead to infections. Interviews with staff, including certified nurse aides and registered nurses, confirmed that the drainage bag was not handled according to the established procedures. The facility's medical director and infection preventionist highlighted the increased risk of infection due to improper handling of the catheter drainage system. The staff's failure to adhere to proper catheter care protocols, such as ensuring the drainage bag was not touching the floor and was positioned correctly, contributed to the resident's risk of developing another urinary tract infection. The deficiency was identified through observations, interviews, and record reviews conducted during the standard survey.

Plan Of Correction

Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 53 was evaluated by the medical provider and noted to be free from infection or signs of UTI. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents utilizing a foley catheter are at risk for the same deficient practice. A full house audit was completed on 2/10/25 to ensure all Foley drainage bags were kept below the residents’ bladder with tubing free of kinks and not placed on the floor. There was no further deficient practice noted. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The facility’s policy titled Catheter Daily Care (Indwelling) was reviewed and no changes are necessary. All nursing staff will be re-educated by the Infection Preventionist on proper care and placement of foley bags and tubing to ensure residents who have an indwelling (Foley) catheter receive the appropriate care and services to manage catheters. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Unit Managers will complete weekly observation audits x 4 weeks, then monthly x 2 months ensuring all foley drainage bags are properly placed below the bladder, that the drainage bag is properly secured before and after transfers, that there is no obstructed urine flow from improperly placed tubing, and that the drainage bag or tubing is not touching the floor. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with emergency preparedness requirements as outlined in Appendix Z of the State Operations Manual. Specifically, the facility did not participate in a full-scale community-based emergency preparedness exercise in 2023, affecting all five resident units. The facility's Emergency Preparedness Manual, reviewed by the Administrator and Assistant Administrator in 2024, stated that the facility would conduct two separate exercises annually, including a community-based full-scale exercise. However, there was no evidence of participation in such an exercise in 2023. Interviews with the Assistant Administrator and Administrator revealed that the facility was a member of the Western New York Mutual Aid Plan but did not participate in any community-wide drills offered in 2023. The Administrator indicated that the responsibility for arranging participation in these drills fell to the Director of Maintenance, who missed the exercise in 2023. Although the Administrator believed there was a loss of power drill involving community partners in 2023, no documentation could be found to support this. Additionally, the Administrator mentioned that the facility likely activated their Emergency Preparedness Plan during a regional blizzard in 2022, but could not recall any activation in 2023. The lack of documentation and participation in required exercises led to the deficiency under 42 CFR 483.73-Emergency Preparedness.

Plan Of Correction

Plan of Correction: Approved February 24, 2025 Corrective action for the deficient practice is to conduct two community-based disaster drills on an annual basis understanding only one is necessary. As participants in the Western New York Mutual Aid plan, the facility is due again in (MONTH) 2025 for an annual drill and will participate in two community-wide drills prior to 10/2025. The Director of Maintenance, Nursing Educator, and Administrator will keep these events in a logbook. The task will also be scheduled in the TELS maintenance program. The Director of Facilities Maintenance for ElderWood LLC will educate the Administrator as well as the Director of Maintenance and Nursing Educator on the requirements for two community-based disaster drills. The schedule and plan for facility inclusion in the two drills will be brought to the QA meeting on a monthly basis, and compliance will be documented at the time of both events. In the event the facility is unable to participate in either of these scheduled events, the facility will determine within 30 days a new date for the missed event to meet this requirement. Policy will be reviewed in Monthly QA for 3 months. Responsible Designee - Maintenance Director

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency identified during the Standard survey was the failure to submit the Termination Form 105 to the New York State Department of Health Criminal History Record Check (CHRC) program within the required thirty-day period after an employee was reassigned or terminated. This issue affected three out of twelve personnel files reviewed. Specifically, the facility did not submit the required termination forms for two housekeeping aides and one certified nurse assistant within the stipulated timeframe. The policy and procedure titled Criminal History Record Check, last modified in April 2024, required the Human Resources Professional to complete the Subject Individual Termination Form for CHRC via the Health Commerce System website within 30 days of a staff member's termination. The personnel records revealed that Housekeeping Aide #1 and Housekeeping Aide #2 received a Pending Denial letter, with their last working days in March 2023, but their Termination Forms were not submitted until May 2023. Similarly, Certified Nurse Aide #8, who did not work in the facility, had a Hold in Abeyance letter dated June 2024, but the Termination Form was not submitted until August 2024. During an interview, the Human Resources Manager, who assumed their position in May 2023, stated they were unaware of the delay in submitting the forms until they conducted a personnel file review. The manager acknowledged that the Termination Form for Certified Nurse Aide #8 should have been submitted by July 2024.

Plan Of Correction

Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The deficient practice has been corrected as required by regulation. The CHRC active roster review shows compliance at this time. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. The CHRC active roster review shows compliance at this time and no recent issues have been identified. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Human resource manager will in-service the recruitment coordinator on the CHRC policy, and the procedure/timing related to removal of terminated employees from the CHRC list. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit of the CHRC active roster will be conducted every 28 days, over the course of the next six months to ensure that only current employees are active. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged violations, including abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than two hours after the allegation was made. Specifically, a Certified Nurse Aide (CNA) witnessed another CNA grab a resident's arms, shake them, and later grab the resident's nose and shake their head during a combative episode. This incident was not reported to the Director of Nursing or the Administrator immediately, resulting in a delay in reporting the alleged abuse to the New York State Department of Health as required by policy. The resident involved had diagnoses including dementia, major depressive disorder, and high blood pressure, and was documented to have severely impaired cognition with daily physical and verbal behaviors directed toward others. The incident occurred during a care routine when the resident became combative. The witnessing CNA did not report the incident until the following day, which was a violation of the facility's policy that mandates immediate reporting of such incidents. Interviews with staff confirmed that the incident should have been reported right away to initiate an investigation and ensure resident safety.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that all alleged allegations of abuse were thoroughly investigated for one resident. Specifically, the facility failed to complete a thorough investigation into an allegation of staff-to-resident physical abuse. The investigation did not include interviews or monitoring of other residents the accused staff member had cared for. The Director of Nursing admitted to not interviewing other residents because it was a memory care unit, and the residents were not considered reliable historians. The Administrator also acknowledged that other residents should have been interviewed to determine the potential impact on them. Resident #1, who had diagnoses including dementia, major depressive disorder, and high blood pressure, was reported to have been physically abused by Certified Nurse Aide #2. The incident was reported to the New York State Department of Health, but the investigation was incomplete as it did not include interviews with other residents. The facility's abuse policy did not specifically include interviewing other residents, which contributed to the incomplete investigation. Additionally, it was found that Certified Nurse Aide #2 had worked on different resident units in the facility, further emphasizing the need for a more comprehensive investigation.